Monkeypox outbreak sparks debate over guidance on sexual behaviors


Public health officials are grappling with how far to go in advising gay men to alter their sexual behavior as the monkeypox virus predominately spreads through their social networks but is a threat to anyone.

The chief World Health Organization specifically advised gay men to reduce their number of sexual partners but others, including the health commissioner in New York City, have warned that abstinence messages don’t work.

The Biden administration is taking a middle road. The Centers for Disease Control and Prevention in recent days updated its guidance to say anyone — not just gay men — can limit their exposure to monkeypox by limiting sexual partners and avoiding “spaces like back rooms, saunas, sex clubs, or private and public sex parties, where intimate, often anonymous sexual contact with multiple partners occurs.”

The updated CDC page features an illustration of two men lying together but its language is broad-based and refers to female body parts, too.

“Every American must do their part to help us beat back monkeypox,” Health and Human Services Secretary Xavier Becerra said Tuesday.

While recent cases in non-endemic countries are concentrated in men who have sex with men, experts say it is only a matter of time before the virus spreads more widely. Illinois health officials on Friday said an adult at an Illinois day care center tested positive for monkeypox, setting off an effort to figure out whether children were exposed and got the virus.

“We’re looking for cases in [the LGBT] community, so we’re finding them there. But we need to start looking for cases in the broader community,” former Food and Drug Commissioner Scott Gottlieb told CBS’s “Face the Nation” on Sunday.

For now, officials estimate that 98% of cases are in men who report having sex with men.

Some experts say messaging is not an either-or debate, and the public health community can help gay men who’ve been hit the hardest by monkeypox without stigmatizing them.

“If we don’t want to repeat the blunders of early days of HIV then we must focus on gay men — that is where the disease is in [the] USA,” said Arthur Caplan, director of the division of medical ethics at the New York University Grossman School of Medicine. “Explain why it is there. Expand testing fast to this group. Initiate contact tracing. Promote healthy sex and healthy hygiene practices. Get the damn vaccines into at-risk arms. Stigma is bad — infected is worse.”

He said it would be best for policymakers to link talk of abstinence with messages on safer sex or good hygiene, akin to general sexual education messaging that includes contraception or counseling about pregnancy alongside abstinence.

The U.S. has reported over 8,900 cases of monkeypox, which is endemic to parts of Africa but started spreading in the U.S. and other non-endemic countries in mid-spring.

Monkeypox is not classified as a sexually transmitted infection and can be spread through other forms of close personal contact.

The virus is related to smallpox and features a rash with painful lesions. A small percentage of cases are fatal, though the CDC hasn’t reported any deaths in the U.S. since cases started to appear in mid-spring.

Other countries, including Brazil and Spain, have reported the first deaths outside of Africa in recent weeks.

Biden officials say they are scrambling to distribute Jynneos vaccines to at-risk persons to wrangle the virus and avoid bad outcomes.

The White House announced a “dose-sparing” plan on Tuesday that involves injecting one-fifth of a dose into the upper layer of skin rather than deeper. The idea is to spur a decent immune response while getting five times as many doses from a single vial of the vaccine.

Demetre Daskalakis, the deputy monkeypox coordinator for President Biden, said advice around sexual activity is “not a forever thing” but a “for-now thing” as officials develop and distribute vaccines and drugs to stop the disease.

“Given the current limited supply of vaccine, consider temporarily changing some behaviors that may increase your risk of being exposed. These temporary changes will help slow the spread of monkeypox until vaccine supply is adequate,” the updated CDC page says.

The White House, meanwhile, said persons in at-risk communities should talk to their doctors about curtailing sex while waiting for a vaccine.

“I am not a medical provider,” White House press secretary Karine Jean-Pierre said Friday. “But I would say talk to your medical provider and get the information that you need so that you are protecting yourself and you know how to move forward.”

Health officials in New York have toured gay bars and taverns to get the word out about monkeypox and vaccines in the hard-hit community. However, New York City Health Commissioner Ashwin Vasan has said that trying to police the LGBT community’s sex practices is stigmatizing and self-defeating.

“Abstinence as a message doesn’t really work. We know this, it’s not a good public health tool because it’s really about giving people the information to make good choices,” he told CNN last month.

Not everyone agrees with the approach. Don Weiss, an epidemiologist in the city health department, has urged city leaders to be more forceful in advising men to abstain from anonymous sex.

“We cannot vaccinate our way out of this, nor can we isolate our way out of this. The only way out is to abstain. I know I sound like a bible-thumping preacher, but this is the exposure we need to PREVENT. We don’t have much time to intervene and it may already be too late,” he said in a June email that was posted online.

Others have taken to social media to point out that members of society were asked to mask up, socially distance and close their businesses during COVID-19, but officials seem unwilling to single out certain behaviors around monkeypox.

WHO Director-General Tedros Adhanom Ghebreyesus said curtailing sex partners is a practical step for gay men, though countries should be careful not to alienate certain communities.

“For men who have sex with men, this includes for the moment, reducing your number of sexual partners, reconsidering considering sex with new partners, and exchanging contact details with any new partners to enable follow-up if needed,” he said in late July, though added: “The stigma and discrimination can be as dangerous as any virus.”

Cameron Bartosiewicz, president of the Youth Pride Association, said the best way to avoid harm or unintended stigma is for officials to focus on providing accurate information and effective guidance to the public, so all individuals can assess their own personal risks and act accordingly.

“The current approach by some public health organizations in telling gay men to practice abstinence is only perpetuating stigmatization and providing a false sense of security among non-LGBTQ populations,” he said.


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